Calcineurin inhibitors

They are not steroids, but both reduce skin inflammation and are used for controlling flare-ups of atopic eczema.

These two medicines work in a different way from all the older treatments for eczema and are an important development in the treatment of this condition.

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Both work by stopping white blood cells in the skin, called T-cells, from producing inflammatory chemicals called cytokines.

These new non-steroid medicines are not regular treatments, but are used to control flare-ups of atopic eczema as and when they occur.

How are they different from corticosteroids?

These medicines are not significantly absorbed through the skin into the bloodstream, which makes them much less likely than steroids to cause side-effects on the rest of the body.

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Due to its structure, pimecrolimus is absorbed less than tacrolimus. And because they don't affect collagen in the skin as topical steroids can, they don't cause the local skin thinning that can be associated with steroids.

Both these factors mean these medicines can be applied to delicate areas of skin such as the face, eyelids, neck and skin folds without problems.

Treatment with these medicines should only be initiated by dermatologists and physicians who have experience in diagnosing and treating atopic eczema.

Using these creams

Pimecrolimus

Pimecrolimus is licensed to treat mild to moderate atopic eczema in adults and children aged two years and over, when the eczema has not been controlled by topical corticosteroid treatment, or if there is a risk of corticosteroid side effects.

The cream should be applied at the first appearance of eczema symptoms, eg redness and itching, to prevent these symptoms getting worse and progressing to a flare-up.

If there is no improvement after six weeks of treatment, or the eczema worsens, treatment with pimecrolimus should be stopped. Continuous long-term use of the cream should be avoided.

Tacrolimus

Tacrolimus comes in two strengths. The 0.1 per cent and 0.03 per cent strengths are licensed for adults.

The weaker 0.03 per cent strength is also licensed to treat moderate to severe atopic eczema in children aged two years and over who have not responded adequately to conventional therapies.

Tacrolimus is used for the short-term relief of eczema symptoms, and as intermittent treatment in the long-term management of eczema.

The ointment should be applied at the first signs of a flare-up of eczema (redness and itching of the skin), as this can help prevent progression to more severe flare-ups.

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If there is no improvement after two weeks of treatment, or the eczema worsens, treatment with tacrolimus should be stopped. Continuous long-term use of the ointment should be avoided.

Both medicines should be applied thinly to the affected areas of skin only.

Avoid getting these medicines in your eyes and avoid contact with areas of skin lining the body cavities (mucous membranes), eg inside the mouth and nose. If these medicines do accidentally come into contact with these areas they should be thoroughly wiped off and/or rinsed off with water.

As with all medicines that you apply to your skin, you should wash your hands thoroughly after applying them, unless the hands are the area being treated.

Airtight dressings (also known as occlusive dressings, and including babies' nappies) should not be applied on top of skin treated with either pimecrolimus or tacrolimus, because they may increase the absorption of these medicines into the body.

What are the possible side-effects?

Pimecrolimus

The most common side-effect of pimecrolimus is a burning sensation at the application site. This is usually mild and short-lived (a few days). If this burning sensation continues after a week the treatment should be stopped.

If you experience a more severe reaction after applying the cream, you should consult your doctor.

Other common side-effects are irritation, itching or redness at the application site and skin infections (folliculitis).

Application site disorders, such as rash, pain, pins and needles sensation, dryness, swelling and worsening of the eczema, are also uncommon.

On rare occasions, people using pimecrolimus cream have experienced symptoms such as skin flushing, rash, burning, itching or swelling shortly after drinking alcohol.

It should not be used by people allergic to macrolactam compounds, which include tacrolimus, sirolimus and ciclosporin.

Pimecrolimus should not be applied to eczema that is infected, or to skin affected by viral infections such as herpes simplex (cold sores) or herpes zoster (chickenpox), because it may make these infections worse.

It's advised that this cream should be applied intermittently, to active areas of eczema only, and patients should limit sun exposure, in order to reduce any potential skin cancer risk.

Tacrolimus

With tacrolimus the most common side-effects are a burning sensation, itching or redness at the application site. These are mild to moderate in severity and tend to resolve within one week of starting treatment. If they haven't resolved, treatment should be stopped.

Other common side-effects include a feeling of warmth, pain, pins and needles or a rash at the application site.

Tacrolimus should not be applied to eczema that is infected, or to skin affected by viral infections such as herpes simplex (cold sores) or herpes zoster (chicken pox), because it may make these infections worse.

Tacrolimus should not be used by pregnant women unless considered essential by a doctor.

It is not recommended for breastfeeding women, and should be used with caution in people who have liver failure.

It's advised that this cream should be applied intermittently, to active areas of eczema only, and patients should limit sun exposure, in order to reduce any potential skin cancer risk.

Calcineurin inhibitors and cancer

A small number of patients who have used these have developed skin cancer or lymphoma, although the link is unproven.

Therefore, as a precaution, the manufacturers recommend that patients should avoid excessive sun exposure and sunburn, and avoid sunbeds and ultraviolet light treatment.

Application of the cream should be limited to the areas of active eczema only, it should only be used intermittently for flare ups, and it should only be used in patients over the age of two.

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